Central serous retinopathy
Encyclopedia
Central serous retinopathy (CSR), also known as central serous chorioretinopathy (CSC), is an eye disease which causes visual impairment
, often temporary, usually in one eye, mostly affecting males in the age group 20 to 50 but which may also affect women. When the disorder is active it is characterized by leakage of fluid under the retina that has a propensity to accumulate under the central macula. This results in blurred or distorted vision (metamorphopsia). A blurred or gray spot in the central visual field is common when the retina is detached. Reduced visual acuity may persist after the fluid has disappeared.
and fluorescein angiography
. The angiography test will usually show one or more fluorescent spots with fluid leakage. In 10%-15% of the cases these will appear in a "classic" smoke stack shape. An Amsler grid
could be useful in documenting the precise area of the visual field
involved.
layers from their supporting tissue. This allows choroid
al fluid to leak into the subretinal space. The build-up of fluid seems to occur because of small breaks in the retinal pigment epithelium.
CSR is sometimes called idiopathic
CSR which means that its cause is unknown. Nevertheless, stress
appears to play an important role. An oft-cited but potentially inaccurate conclusion is that persons in stressful occupations, such as airplane pilots, have a higher incidence of CSR.
The "type A personality
" has also been linked to this condition. However, the statistics may be skewed by the fact that CSR often goes undiagnosed or misdiagnosed; airline pilots and so-called "type A" people are demonstrably exacting, demanding people with (certainly in the case of pilots) better-than-average vision. They are more likely than the general population to notice the sometimes-subtle degradation of vision caused by CSR and insist on a believable diagnosis of it. People who need glasses may assume that the blurriness caused by CSR is simply a change in their prescription, and fail to have the condition assessed by a retinal specialist. These statistic-skewing factors undermine the conclusion that CSR is a condition specific to "type A" people.
CSR has also been associated with cortisol
and corticosteroids. Persons with CSR have higher levels of cortisol. Cortisol is a hormone
secreted by the adrenal cortex
which allows the body to deal with stress, which may explain the CSR-stress association. There is extensive evidence to the effect that corticosteroids (e.g. cortisone
) — commonly used to treat inflammations, allergies, skin conditions and even certain eye conditions — can trigger CSR, aggravate it and cause relapses. A study of 60 persons with Cushing's syndrome
found CSR in 3 (5%). Cushing's syndrome is characterized by very high cortisol levels.
Recently found evidence has also implicated Helicobacter pylori
(see gastritis
) as playing a role. It would appear that the presence of the bacteria is well correlated with
visual acuity
and other retinal findings following an attack.
Recent evidence also shows that sufferers of MPGN Type II kidney disease can develop retinal abnormalities including CSR caused by deposits of the same material that originally damaged the glomerular basement membrane
in the kidneys.
Some visual abnormalities can remain even if visual acuity
is measured at 20/20, and lasting problems include decreased night vision
,
reduced color discrimination, and localized distortion.
Complications include subretinal neovascularization and
pigment epitheliopathy.
The disease can re-occur causing progressive vision loss.
There is also a chronic form, titled as Type II Central Serous Retinopathy, this occurs in approximately 5% of cases. This exhibits diffuse rather than focalized abnormality of the pigment epithelium, producing a persistent subretinal fluid. The serous fluid in these cases tends to be shallow rather than dome shaped. Prognosis for this condition is less favorable and continued clinical consultation
is advised.
should be immediately performed to rule out Retinal Detachment
, which is a medical emergency. Additionally, a clinical record should be taken to give a timeline of the detachment.
Any ongoing corticosteroid treatment should be stopped, where possible. It is important to check current medication, including nasal sprays and creams, for ingredients of corticosteroids, if found seek advice from a medical practitioner for an alternative.
Patients sometimes present with an obvious history of psychosocial stress, in which case counselling and expectancy is relevant.
The disease is often treated, if it does not disappear within a few months, spontaneously or as the result of counselling. There is no high-level evidence to support any specific mode of treatment.
Laser photocoagulation
, which effectively burns the leak area shut, may be considered in cases where there is little improvement in a 3 to 4 month duration, and the leakage is confined to a single or a few sources of leakage at a safe distance from the fovea
. However, for many cases the leak is very near the central macula, where photocoagulation would leave a blind spot or the leakage is widespread and its source is difficult to identify. Recently, verteporfin
-photodynamic therapy
has became an option for treating chronic cases near the fovea.
Foveal attenuation has been associated with more than 4 months' duration of symptoms, however a better long-term outcome has not been demonstrated with laser photocoagulation than without photocoagulation. Equally, photodynamic therapy
has not yet been clinically proven to offer a better long term outcome.
Transpupillary thermotherapy has been suggested as a lower-risk alternative to laser photocoagulation in cases where the leak is in the central macula.
Bromfenac
has also been shown to alleviate the condition in some cases.
If co-existing with gastro-intestinal disorder, anti-microbial treatment could be considered, in light of recent findings associating Helicobacter pylori
increasing the likelihood of the disease.
Nutritional supplements commonly recommended for Macular Degeneration
, such as Lutein
and Zeaxanthin
, may assist healing.
Unfortunately, research has not found absolute indication of any drug therapy to be a treatment of the disease.
Visual impairment
Visual impairment is vision loss to such a degree as to qualify as an additional support need through a significant limitation of visual capability resulting from either disease, trauma, or congenital or degenerative conditions that cannot be corrected by conventional means, such as refractive...
, often temporary, usually in one eye, mostly affecting males in the age group 20 to 50 but which may also affect women. When the disorder is active it is characterized by leakage of fluid under the retina that has a propensity to accumulate under the central macula. This results in blurred or distorted vision (metamorphopsia). A blurred or gray spot in the central visual field is common when the retina is detached. Reduced visual acuity may persist after the fluid has disappeared.
Diagnosis
The diagnosis usually starts with a dilated examination of the retina, followed with confirmation by optical coherence tomographyOptical coherence tomography
Optical coherence tomography is an optical signal acquisition and processing method. It captures micrometer-resolution, three-dimensional images from within optical scattering media . Optical coherence tomography is an interferometric technique, typically employing near-infrared light...
and fluorescein angiography
Fluorescein angiography
Intravenous Fluorescein angiography or fluorescent angiography is a technique for examining the circulation of the retina using the dye tracing method...
. The angiography test will usually show one or more fluorescent spots with fluid leakage. In 10%-15% of the cases these will appear in a "classic" smoke stack shape. An Amsler grid
Amsler grid
The Amsler grid, used since 1945, is a grid of horizontal and vertical lines used to monitor a person's central visual field. The grid was developed by Marc Amsler, a Swiss ophthalmologist. It is a diagnostic tool that aids in the detection of visual disturbances caused by changes in the retina,...
could be useful in documenting the precise area of the visual field
Visual field
The term visual field is sometimes used as a synonym to field of view, though they do not designate the same thing. The visual field is the "spatial array of visual sensations available to observation in introspectionist psychological experiments", while 'field of view' "refers to the physical...
involved.
Causes
CSR is a fluid detachment of maculaMacula
The macula or macula lutea is an oval-shaped highly pigmented yellow spot near the center of the retina of the human eye. It has a diameter of around 5 mm and is often histologically defined as having two or more layers of ganglion cells...
layers from their supporting tissue. This allows choroid
Choroid
The choroid, also known as the choroidea or choroid coat, is the vascular layer of the eye, containing connective tissue, and lying between the retina and the sclera. The human choroid is thickest at the far extreme rear of the eye , while in the outlying areas it narrows to 0.1 mm...
al fluid to leak into the subretinal space. The build-up of fluid seems to occur because of small breaks in the retinal pigment epithelium.
CSR is sometimes called idiopathic
Idiopathic
Idiopathic is an adjective used primarily in medicine meaning arising spontaneously or from an obscure or unknown cause. From Greek ἴδιος, idios + πάθος, pathos , it means approximately "a disease of its own kind". It is technically a term from nosology, the classification of disease...
CSR which means that its cause is unknown. Nevertheless, stress
Stress (medicine)
Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...
appears to play an important role. An oft-cited but potentially inaccurate conclusion is that persons in stressful occupations, such as airplane pilots, have a higher incidence of CSR.
The "type A personality
Type A personality
Originally published in the 1950s, the Type A and Type B personality theory is a theory which describes two common, contrasting personality types—the high-strung Type A and the easy-going Type B—as patterns of behavior that could either raise or lower, respectively, one's chances of developing...
" has also been linked to this condition. However, the statistics may be skewed by the fact that CSR often goes undiagnosed or misdiagnosed; airline pilots and so-called "type A" people are demonstrably exacting, demanding people with (certainly in the case of pilots) better-than-average vision. They are more likely than the general population to notice the sometimes-subtle degradation of vision caused by CSR and insist on a believable diagnosis of it. People who need glasses may assume that the blurriness caused by CSR is simply a change in their prescription, and fail to have the condition assessed by a retinal specialist. These statistic-skewing factors undermine the conclusion that CSR is a condition specific to "type A" people.
CSR has also been associated with cortisol
Cortisol
Cortisol is a steroid hormone, more specifically a glucocorticoid, produced by the adrenal gland. It is released in response to stress and a low level of blood glucocorticoids. Its primary functions are to increase blood sugar through gluconeogenesis; suppress the immune system; and aid in fat,...
and corticosteroids. Persons with CSR have higher levels of cortisol. Cortisol is a hormone
Hormone
A hormone is a chemical released by a cell or a gland in one part of the body that sends out messages that affect cells in other parts of the organism. Only a small amount of hormone is required to alter cell metabolism. In essence, it is a chemical messenger that transports a signal from one...
secreted by the adrenal cortex
Adrenal cortex
Situated along the perimeter of the adrenal gland, the adrenal cortex mediates the stress response through the production of mineralocorticoids and glucocorticoids, including aldosterone and cortisol respectively. It is also a secondary site of androgen synthesis.-Layers:Notably, the reticularis in...
which allows the body to deal with stress, which may explain the CSR-stress association. There is extensive evidence to the effect that corticosteroids (e.g. cortisone
Cortisone
Cortisone is a steroid hormone. It is one of the main hormones released by the adrenal gland in response to stress. In chemical structure, it is a corticosteroid closely related to corticosterone. It is used to treat a variety of ailments and can be administered intravenously, orally,...
) — commonly used to treat inflammations, allergies, skin conditions and even certain eye conditions — can trigger CSR, aggravate it and cause relapses. A study of 60 persons with Cushing's syndrome
Cushing's syndrome
Cushing's syndrome is a hormone disorder caused by high levels of cortisol in the blood. This can be caused by taking glucocorticoid drugs, or by tumors that produce cortisol or adrenocorticotropic hormone or CRH...
found CSR in 3 (5%). Cushing's syndrome is characterized by very high cortisol levels.
Recently found evidence has also implicated Helicobacter pylori
Helicobacter pylori
Helicobacter pylori , previously named Campylobacter pyloridis, is a Gram-negative, microaerophilic bacterium found in the stomach. It was identified in 1982 by Barry Marshall and Robin Warren, who found that it was present in patients with chronic gastritis and gastric ulcers, conditions that were...
(see gastritis
Gastritis
Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic...
) as playing a role. It would appear that the presence of the bacteria is well correlated with
visual acuity
Visual acuity
Visual acuity is acuteness or clearness of vision, which is dependent on the sharpness of the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain....
and other retinal findings following an attack.
Recent evidence also shows that sufferers of MPGN Type II kidney disease can develop retinal abnormalities including CSR caused by deposits of the same material that originally damaged the glomerular basement membrane
Glomerular basement membrane
The glomerular basement membrane is the basal laminal portion of the glomerulus. The Glomerular capillary endothelial cells, the GBM and the filtration slits between the podocytes perform the filtration function of the glomerulus, separating the blood in the capillaries from the filtrate that...
in the kidneys.
Prognosis
The prognosis for CSR is generally excellent. Whilst immediate vision loss maybe as poor as 20/200, clinically over 90% of patients regain 20/30 vision or better within 6 months.Some visual abnormalities can remain even if visual acuity
Visual acuity
Visual acuity is acuteness or clearness of vision, which is dependent on the sharpness of the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain....
is measured at 20/20, and lasting problems include decreased night vision
Night vision
Night vision is the ability to see in low light conditions. Whether by biological or technological means, night vision is made possible by a combination of two approaches: sufficient spectral range, and sufficient intensity range...
,
reduced color discrimination, and localized distortion.
Complications include subretinal neovascularization and
pigment epitheliopathy.
The disease can re-occur causing progressive vision loss.
There is also a chronic form, titled as Type II Central Serous Retinopathy, this occurs in approximately 5% of cases. This exhibits diffuse rather than focalized abnormality of the pigment epithelium, producing a persistent subretinal fluid. The serous fluid in these cases tends to be shallow rather than dome shaped. Prognosis for this condition is less favorable and continued clinical consultation
Doctor-patient relationship
The doctor-patient relationship is central to the practice of healthcare and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. The doctor-patient relationship forms one of the foundations of contemporary medical ethics...
is advised.
Treatment
Differential diagnosisDifferential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
should be immediately performed to rule out Retinal Detachment
Retinal detachment
Retinal detachment is a disorder of the eye in which the retina peels away from its underlying layer of support tissue. Initial detachment may be localized, but without rapid treatment the entire retina may detach, leading to vision loss and blindness. It is a medical emergency.The retina is a...
, which is a medical emergency. Additionally, a clinical record should be taken to give a timeline of the detachment.
Any ongoing corticosteroid treatment should be stopped, where possible. It is important to check current medication, including nasal sprays and creams, for ingredients of corticosteroids, if found seek advice from a medical practitioner for an alternative.
Patients sometimes present with an obvious history of psychosocial stress, in which case counselling and expectancy is relevant.
The disease is often treated, if it does not disappear within a few months, spontaneously or as the result of counselling. There is no high-level evidence to support any specific mode of treatment.
Laser photocoagulation
Laser photocoagulation
Laser coagulation or laser photocoagulation surgery is used to treat a number of eye diseases and has become widely used in recent decades...
, which effectively burns the leak area shut, may be considered in cases where there is little improvement in a 3 to 4 month duration, and the leakage is confined to a single or a few sources of leakage at a safe distance from the fovea
Fovea
The fovea centralis, also generally known as the fovea , is a part of the eye, located in the center of the macula region of the retina....
. However, for many cases the leak is very near the central macula, where photocoagulation would leave a blind spot or the leakage is widespread and its source is difficult to identify. Recently, verteporfin
Verteporfin
Verteporfin , a benzoporphyrin derivative, is a medication used as a photosensitizer for photodynamic therapy to eliminate the abnormal blood vessels in the eye associated with conditions such as the wet form of macular degeneration...
-photodynamic therapy
Photodynamic therapy
Photodynamic therapy is used clinically to treat a wide range of medical conditions, including malignant cancers, and is recognised as a treatment strategy which is both minimally invasive and minimally toxic...
has became an option for treating chronic cases near the fovea.
Foveal attenuation has been associated with more than 4 months' duration of symptoms, however a better long-term outcome has not been demonstrated with laser photocoagulation than without photocoagulation. Equally, photodynamic therapy
Photodynamic therapy
Photodynamic therapy is used clinically to treat a wide range of medical conditions, including malignant cancers, and is recognised as a treatment strategy which is both minimally invasive and minimally toxic...
has not yet been clinically proven to offer a better long term outcome.
Transpupillary thermotherapy has been suggested as a lower-risk alternative to laser photocoagulation in cases where the leak is in the central macula.
Bromfenac
Bromfenac
Bromfenac is a non-steroidal anti-inflammatory drug marketed in the US as an ophthalmic solution by ISTA Pharmaceuticals for short-term, local use...
has also been shown to alleviate the condition in some cases.
If co-existing with gastro-intestinal disorder, anti-microbial treatment could be considered, in light of recent findings associating Helicobacter pylori
Helicobacter pylori
Helicobacter pylori , previously named Campylobacter pyloridis, is a Gram-negative, microaerophilic bacterium found in the stomach. It was identified in 1982 by Barry Marshall and Robin Warren, who found that it was present in patients with chronic gastritis and gastric ulcers, conditions that were...
increasing the likelihood of the disease.
Nutritional supplements commonly recommended for Macular Degeneration
Macular degeneration
Age-related macular degeneration is a medical condition which usually affects older adults and results in a loss of vision in the center of the visual field because of damage to the retina. It occurs in “dry” and “wet” forms. It is a major cause of blindness and visual impairment in older adults...
, such as Lutein
Lutein
Lutein is a xanthophyll and one of 600 known naturally occurring carotenoids. Lutein is synthesized only by plants and like other xanthophylls is found in high quantities in green leafy vegetables such as spinach and kale...
and Zeaxanthin
Zeaxanthin
Zeaxanthin is one of the most common carotenoid alcohols found in nature. It is important in the xanthophyll cycle. Synthesized in plants & some micro-organisms, it is the pigment that gives paprika , corn, saffron, and many other plants & microbes their characteristic color.The name is derived...
, may assist healing.
Unfortunately, research has not found absolute indication of any drug therapy to be a treatment of the disease.
See also
- CortisolCortisolCortisol is a steroid hormone, more specifically a glucocorticoid, produced by the adrenal gland. It is released in response to stress and a low level of blood glucocorticoids. Its primary functions are to increase blood sugar through gluconeogenesis; suppress the immune system; and aid in fat,...
- Cushing's syndromeCushing's syndromeCushing's syndrome is a hormone disorder caused by high levels of cortisol in the blood. This can be caused by taking glucocorticoid drugs, or by tumors that produce cortisol or adrenocorticotropic hormone or CRH...
- Diabetic retinopathyDiabetic retinopathyDiabetic retinopathy is retinopathy caused by complications of diabetes mellitus, which can eventually lead to blindness....
- Hypertensive retinopathyHypertensive retinopathyHypertensive retinopathy is damage to the retina due to high blood pressure .-Pathophysiology:The retina is one of the "target organs" that are damaged by sustained hypertension....
- Macular degenerationMacular degenerationAge-related macular degeneration is a medical condition which usually affects older adults and results in a loss of vision in the center of the visual field because of damage to the retina. It occurs in “dry” and “wet” forms. It is a major cause of blindness and visual impairment in older adults...
- Posterior vitreous detachmentPosterior vitreous detachmentA posterior vitreous detachment is a condition of the eye in which the vitreous humour separates from the retina.Broadly speaking, the condition is common for older adults and over 75% of those over the age of 65 develop it. Although less common among people in their 40s or 50s, the condition is...
- StressStress (medicine)Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...